Prevalence and predictors of musculoskeletal injuries among gym members in Bangladesh: A nationwide cross-sectional study

Background Participating in physical exercise is advantageous for maintaining optimum health, improving physical capacity, decreasing the likelihood of chronic diseases, and promoting overall wellbeing. Aim This study aimed to find out the prevalence and factors that contribute to musculoskeletal injuries among individuals who participated in fitness activities at the gym. Methods This cross-sectional study included 1123 gym members, both male and female, aged between 18 and 50 years, from selected fitness centers in Bangladesh. Musculoskeletal injuries were assessed using the Nordic musculoskeletal disorder questionnaire. Binary logistic regression identified the gym members’ predictors of musculoskeletal injuries. Results The highest prevalence of musculoskeletal injuries at the low back (36.6%) was seen among the eight body sites, followed by the shoulder (24.7%) and knee (17.1%). Males (aOR 2.589, CI 1.18 to 5.65) and those who go to the gym to lose weight (aOR 3.859, CI 0.91 to 16.33) and for physical fitness (aOR 1.895, CI 1.07 to 3.35) had a greater risk of musculoskeletal injury. Participants who carried out strength training exercises (aOR 4.10, CI 2.74 to 6.19) had a four-fold increased risk of musculoskeletal injuries than those who did not. Furthermore, higher adjusted odds of musculoskeletal injuries were found for the potential causes of injuries in incorrect holding (aOR 1.69, CI 1.10 to 2.60), overweight lifting (aOR 2.00, CI 1.30 to 3.08), lack of workout knowledge (aOR 3.56, CI 2.09 to 5.85), and insufficient information from the trainer (aOR 5.66, CI 1.84 to 17.39). Conclusion Musculoskeletal injuries are highly prevalent among gym-goers in Bangladesh. The back was the most often injured area, followed by the shoulder and knee. It is important to exhibit caution and take extra care while doing strength training activities in order to avoid injury. Prior to engaging in gym-based activities, it is essential to have a thorough understanding of proper exercise knowledge.

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Competing Interests
Use the instructions below to enter a competing interest statement for this submission.On behalf of all authors, disclose any competing interests that could be perceived to bias this work-acknowledging all financial support and any other relevant financial or nonfinancial competing interests.This statement is required for submission and will appear in the published article if the submission is accepted.Please make sure it is accurate and that any funding sources listed in your Funding Information later in the submission form are also The authors have clarified that there are no competing interests.Yes -all data are fully available without restriction Aim: This study aimed to find out the prevalence and factors that contribute to musculoskeletal injuries among individuals who participated fitness activities at the gym.

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Methods: Cross-sectional research was undertaken from 25 th June to 30 th December 2022.The survey was conducted via in-person interviews with gym members aged 18 to 50 years in Bangladesh using a structured questionnaire.The descriptive analysis facilitated the calculation of musculoskeletal pain prevalence.The gym members' predictors of musculoskeletal injuries were identified by regression analysis.

Results:
The highest prevalence of musculoskeletal injuries at low back (36.6%) was seen among the eight body sites, followed by shoulder (24.7%) and knee (17.1%).Males (aOR 2.589, CI 1.18 to 5.65) those who go to the gym to lose weight (aOR 3.859, CI 0.91 to 16.33) and for physical fitness (aOR 1.895, CI 1.07 to 3.35) had a greater risk of musculoskeletal injury.Participants who carried out strength training exercises (aOR 4.10, CI 2.74 to 6.19) had a four-fold increased risk of musculoskeletal injuries than those who did not.Furthermore, higher adjusted odds of musculoskeletal injuries were found for the potential causes of injuries in incorrect holding (aOR 1.69, CI 1.10 to 2.60), overweight lifting (aOR 2.00, CI 1.30 to 3.08), lack of workout knowledge (aOR 3.56, CI 2.09 to 5.85), insufficient information from the trainer (aOR 5.66, CI 1.84 to 17.39).

Introduction
Engaging in physical exercise is beneficial for maintaining optimal health, enhancing physical performance, reducing the risk of chronic diseases, and enhancing overall well-being (1,2).Fitness centers serve as a vital hub for engaging in physical activity, where members tend to exercise more often than they typically do in their own homes (3,4).In 2016, the gym-based exercise participation rate among Dutch residents aged 12-79 was 21 percent, which is an increase from 12 percent in 2001 (5).Gym-based fitness activities provide a range of exercise facilities in a secure environment, promoting social engagement, and giving members access to expert's exercise instruction and coaching (3).While engaging in physical activity via sports is generally seen as advantageous, participating in fitness activities in the gym is linked to the potential for injuries (6).
A descriptive epidemiological study in the Netherlands shows that many injuries occur as a result of gym-based fitness activities (6).In 2019, the total number of reported injuries resulting from fitness activities in gyms amounted to 860,000, which constituted 16% of all sports injuries in the Netherlands (7).
A research study was conducted in the Netherlands including 494 Dutch citizens who engage in exercise activities at gyms on a daily basis.Based on the survey findings, the predominant occurrence of injuries was seen during the practice of strength training.The shoulder, leg, and knee were the primary anatomical areas impacted by injury, with unsupervised gym-based exercise activities responsible for 73.1% of the reported injuries (6).Another study in South Florida revealed that out of 191 athletes, 50 individuals had a collective total of 62 injuries while participating in CrossFit over a period of 6 months (8).Research conducted in Saudi Arabia examined the occurrence of injuries among individuals who are members of gyms.The survey revealed that 29.2% of the participants reported experiencing musculoskeletal injuries.The shoulder accounted for 40.5% of injuries, followed by the foot at 32.4% and the back at 25.7% (9).
The predominant emphasis of research on exercise-related injuries in gyms has been on injuries treated in emergency departments (9), as well as injuries associated with particular exercise programs such as CrossFit (10)(11)(12), powerlifting, and weightlifting (13,14).Various fitness activities, such as CrossFit and power-and weightlifting, have undergone thorough investigation in several countries.The recent systematic reviews have collated and examined the results of these investigations (11)(12)(13).In a study conducted by Lubetzky-Vilnai A et.al., it was shown that 41.6% of the total participants (190 out of 457 persons) reported experiencing exercise-related injuries in the gym (15).The published results are limited to certain age groups, specific fitness activities performed in gyms, and injuries associated with fitness that were treated at emergency rooms.
Nevertheless, these rules do not include the whole population involved in fitness activities or those specifically conducted in gyms.In order to provide appropriate guidance and education on preventing gym-related injuries, it is essential to collect extensive data on these injuries across the wider recreational exercise community.Specific data about the total number of injuries resulting from workout activities in gyms can be obtained from countries such as The Netherlands (6) and Saudi Arab (9).Nevertheless, the comprehension of this information is restricted and there is a paucity of data regarding the prevalence and predictors of gym-related injuries.This is the first study which addressed the serious issue here in Bangladesh.The objective of this research was to determine the prevalence and factors that contribute to musculoskeletal injuries among individuals who participated fitness activities at the gyms in Bangladesh.

Study design and participants
A descriptive cross-sectional study was conducted in Bangladesh from 25 th June to 30 th December 2022 to collect information about individuals who participate in fitness activities in gyms.The data was collected via face-to-face interviews.Due to the lack of available data on the total number of gym centers in Bangladesh and the number of individuals who regularly attend gyms, we conducted a random visit to gym facilities in five cities.In order to streamline data collection, we made a single visit to each gym facility and gathered data from the fitness trainees who were there at the time.

Ethical statement
This study adhered to the ethical standards for medical research with human participants as outlined in the World Medical Association Declaration of Helsinki (Revised 2013).A local ethical review board (Approval No: ICE/physio/22/008) approved the study protocol.The study rigorously followed the Strengthening the Reporting of Observational Studies in Epidemiology guideline for cross-sectional studies.Before commencing the individual interview session, written informed consent was obtained by offering a comprehensive explanation of the study's aim, objectives, potential benefits, and dangers.The participants were also informed of the voluntary nature of the interview and their participation.

Subject selection criteria
The research included participants between the ages of 18 and 50, of both genders, who agreed to participate.The research eliminated those with a history of non-gym-related injuries, as well as those with musculoskeletal or neurological diseases, and participants who were using steroids.

Sample and sample size
The necessary sample size for this cross-sectional study was determined using the method for determining proportions: n = Zα 2 P (1 − P)/d 2 ; where Zα =1.96; P = the expected musculoskeletal injuries reported in the previous literature; as we don't have any previous literature available regarding this issue, we assume 50% response distribution and d = 3% marginal error (16).Thus, the study found that a minimum sample size of 1067 was required.Based on an anticipated 10% incidence of incomplete forms, we have calculated that the absolute minimum required sample size should be 1173.A total of 1250 people were interviewed, resulting in the attainment of the final sample.Nevertheless, 44 individuals failed to respond to all the questions, so we exclude them from the final analysis.

Survey questionnaire
The questionnaire encompasses demographic data (age, gender, height, weight, BMI and occupation), workout-related details (reason for joining the gym, daily workout duration, types of exercises performed at the gym, adequacy of instructor's attention during workouts, and inclusion of warm-up/cool-down activities), injury-related information (history of previous workout-related injuries, possible causes of injury, current pain status, continuation of workouts after an injury, adherence to rest periods following an injury, and injury management strategies).
The Nordic musculoskeletal disorder questionnaire served as a tool for pinpointing the location of pain.The questionnaire included eight distinct anatomical locations where pain was experienced, namely the neck, shoulder, elbow, wrist/hand, back, hip/thigh, knee, and ankle/foot.
The Nordic musculoskeletal questionnaire's validity has been previously demonstrated in existing research (17).The questionnaire have a sensitivity for detecting pain in the body ranged from 66% to 92%, while the specificity ranged from 71% to 88% (18).

Data collection procedure
The survey was conducted using an interviewer-administered questionnaire.Eight data collectors, all of whom have graduated in physiotherapy, were selected for the purpose of data collection.The interview was conducted in Bangla.Data was gathered from five divisions of Bangladesh, where 74 fitness facilities were visited in a random manner for the purpose of data collection.Illegible participants were requested to participate in this study.Informed consent to collect, analyze, and publish their data anonymously was obtained before starting an interview.Upon receiving authorization, a data collector conducted an interview and completed a questionnaire using a paperbased format.Initially, the data collector posed a question to the respondent, and upon receiving an answer, the data collector repeated the response to the respondent in order to get confirmation.

Statistical analysis
The descriptive data were presented as frequency, percentage, mean, and standard deviation, where applicable.In order to establish the correlation between musculoskeletal pain and sociodemographic characteristics, the Pearson's Chi-square test or Fisher's exact test were used.
Multiple logistic regression analysis was conducted to calculate adjusted and un-adjusted odds ratios with a 95% confidence interval.The independent variables in this study were the presence of pain, and socio-demographic characteristics, and workout-related information as predictor variables for musculoskeletal pain.The variables were found to be statistically significant in the descriptive analysis was included into the regression model for the computation of adjusted odds ratios (aORs).The Hosmer-Lemeshow goodness-of-fit test was used to verify that the models sufficiently conform to the data.The significance level was established at <0.05.The statistical analysis was conducted using IBM SPSS Version 25.

Participants' general characteristics
In total, this study examined the data of 1123 individuals.The average age, weight, height, and Body Mass Index (BMI) of the participants were 27.16 ± 6.58 years, 69.60 ± 10.67 kg, 168.59 ± 7.26 cm, and 24.28 ± 3.58 kg/m2, respectively.Table 1 presents the statistical summary of the sociodemographic characteristics.Out of the total respondents, 1039 (92.0%) were male and 538 (47.7%) belonged to the age range of 18-25 years, and 458 (40.6%) were service holder.Based on the BMI Asian classification, 442 (39.1%) of the individuals in the study were classified as obese, while 615 (54.5%) of the participants reported going to the gym to maintain their physical fitness.
Out of the total participants, about 540 (47.8%) worked out for at least an hour in the gym additionally, 88.2% of the participants incorporated warm up and cooldown exercises into their routine.Of them, 67.8% did aerobic activities, 67.5% strength training, 50.0%powerlifting, and 42.8% CrossFit exercises.25% of participants ascribed their injuries to excessive exercise, 19.9% to improper grip, 22.1% to lifting weights above their capacity, 15.3% to insufficient knowledge of exercise techniques, 5.6% to inadequate guidance from the trainer, and 16.3% to a lack of caution during exercise.

Prevalence of musculoskeletal injuries 217
The highest prevalence of musculoskeletal injuries at low back (17.2%) was seen among the eight 218 body sites, followed by shoulder (11.0%) and knee (7.6%).Moreover, 3.8% of the participants 219 reported neck injuries, whereas 6.5% and 4.6% reported hip/thigh and ankle/foot injuries.Fig 1 220 shows the prevalence of musculoskeletal injuries among the participants.34.5% of participants 221 had encountered an injury at least once, whereas 25.6% of participants had experienced many 222 instances of injuries during previous workout sessions.49.1% of participants continued their workout after their injury, and 63.6% of the participants left their injury untreated or managed by themselves.

Result of regression analysis
Males (aOR 2.589, CI 1.18 to 5.65) and those over 45 years of age (aOR 1.069, CI 0.19 to 6.03) had higher chances of musculoskeletal injury.Furthermore, those who go to the gym to lose weight

Discussion
Musculoskeletal injuries are highly prevalent among gym members in Bangladesh.Out of the eight body locations, the low back had the highest occurrence of musculoskeletal injuries, followed by the shoulder and knee.Males who work-out at the gym to improve their physical fitness and to reduce their body weight are more likely to suffer from musculoskeletal injuries.The risk of musculoskeletal injuries was four times higher for those who performed strength training activities compared to those who did not.In addition, there were increased possibilities of musculoskeletal injuries when it came to inappropriate gripping, lifting weights that are too heavy, not knowing how to work-out, and not receiving adequate advice from their trainer.
The most common site of injury was the back (17.2%),followed by the shoulder (11.0%) and the knee (7.6%).Similar to our result, we found that the study conducted by Ahmed et al.
reported that back was the most commonly affected site for gym injuries, followed by the shoulder and knee.In contrast to our study, Shinde and Sahasrabuddhe reported the shoulder as the most commonly affected site for gym injuries, followed by the lower back and knee (19).The study of Feito et al. also reported that the shoulder was the most commonly affected site followed by the back, and knee (20).
Furthermore, this investigation revealed that male and those aged 45 and above had elevated susceptibility to musculoskeletal injury.Feito et al. observed a significantly higher incidence of injuries among men compared to women in their study (20).Another study found a significant difference in gym-related injuries between men and women, with men exhibiting a much higher incidence of injuries in contrast to females.However, age was not proven to be a major contributing factor (9  2022), fitness participants who were taught by less experienced trainers had a risk of experiencing discomfort at various locations that was more than double compared to those trained by more experienced trainers (25).

Strength and limitations
Questionnaires given by face-to-face interviewers are more accurate and have more validity as they decrease non-response and misclassification bias.The results may be more broadly applicable as a result of the random sample technique used to include the whole population which minimize the selection bias.Incorporating the nationwide population of the country may enhance the generalizability of the results.However, there are also a number of limitations to this research.
First off, the reason for the correlation between the independent and dependent variables cannot be determined by this cross-sectional research.Second, since this research was conducted in urban regions, its findings may not apply to Bangladesh's other rural communities.Furthermore, the questionnaire relied on some inquiries that necessitated participants to recollect past occurrences, thus resulting in recall bias.Future research should prioritize the collection of data pertaining to the characteristics of injuries and the specific treatment protocols necessary for their management.

Conclusion:
Gym-goers in Bangladesh often have muscular injuries.The back was the most often injured area, followed by the shoulder and knee.Individuals of the male gender and those aged 45 and above had elevated probabilities of experiencing musculoskeletal injury.In addition, those who visit the gym with the intention of weight loss and improving physical fitness are at a higher risk of experiencing musculoskeletal injuries.Individuals who engaged in strength training activities had a risk of musculoskeletal injuries that was four times higher compared to those who disclosure statement that describes the sources of funding for the work included in this submission.Review the submission guidelines for detailed requirements.View published research articles from PLOS ONE for specific examples.
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Table 1
Trainees' demographic details aOR 3.859, CI 0.91 to 16.33) and for physical fitness (aOR 1.895, CI 1.07 to 3.35) had a greater risk of musculoskeletal injury.Participants who carried out strength training exercises (aOR 4.10, CI 2.74 to 6.19) had a four-fold increased risk of musculoskeletal injuries than those who did not.
Furthermore, higher adjusted odds of musculoskeletal injuries were found for the potential causes of injuries in incorrect holding (aOR 1.69, CI 1.10 to 2.60), overweight lifting (aOR 2.00, CI 1.30 to 3.08), lack of workout knowledge (aOR 3.56, CI 2.09 to 5.85), insufficient information from the trainer (aOR 5.66, CI 1.84 to 17.39), and who were not cautious during exercise (aOR 2.878, CI 1.77 to 4.66).However, those who did not do a warm-up and cool-down before to exercise had a substantially greater risk of musculoskeletal pain (aOR 2.671, CI 1.61 to 4.41).Table2gives the entire findings.

Table 3
Multiple logistic regression analysis: predictor of musculoskeletal injuries among the (24)(22)(23)ss, several research studies have shown a lack of substantial disparity between males and females in terms of injury rates(21)(22)(23).Our research found that those who participated in strength training activities had a fourfold increased probability of experiencing musculoskeletal injuries.These findings align with the data reported byKemler et al.indicating that 52% of the participants engaged in strength training, and most of the injuries occurred during strength training activities(6).According to Gray and Finch, 55% of the injuries occurring in fitness centers and requiring treatment in emergency rooms are specifically associated with strength training.Gray and Finch also examined the precise etiology of the injuries sustained(23).They found overexertion or vigorous and/or abnormal movement emerged as a significant factor contributing to injuries in their research.Kemler et al.found that injury was most often attributed to overuse, overload, missteps and sprains, or poor posture or movement(6).Our study also found a few contributing factors, for instance, overexercise, wrong holding, overweight lifting, a lack of workout knowledge, inadequate information from the trainer, and not being cautious during exercise.Gray and Finch conducted an analysis of injuries treated in emergency departments, whereas we examined all injuries experienced by a representative sample of individuals engaged in fitness activities.This disparity in methodology might account for the variation in identified causes.In this study, individuals who had inadequate knowledge about exercises saw a fourfold increase in injuries, while those who did not get sufficient guidance from their trainer experienced a fivefold increase in injuries.A recent review has identified several factors that can contribute to injuries during resistance training.These include overuse, insufficient rest periods after exercise, inadequate conditioning of the targeted body parts, excessive use of heavy loads, improper technique during certain exercises, and the abuse of performance-enhancing drugs(24).We firmly feel and concur that in order to avoid injuries, it is crucial to provide close monitoring and guidance on proper technique and movement during this particular activity, ideally with the assistance of a trainer.Exercises that are more intricate may need trainers with more expertise, since the trainers' experience may significantly influence the trainees' musculoskeletal discomfort.According to research conducted byAhmed et al. ( not participate in such exercises.It is important to exhibit caution and take extra care while doing strength training activities in order to avoid injury.Prior to engaging in gym-based activities, it is essential to have a thorough understanding of proper exercise knowledge.musculoskeletal pain: A cross-sectional study.Sports.2022 Jun 1;10(xxx):xxx.
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